Biographical Information

Biographical Information

1 question out of 15 has been autopopulated and highlighted in green in this section. Please review below and save.

1. Race/Ethnicity *

Caucasian-White
African American
Hispanic-Latino
Asian
Middle Eastern
Native American
East Indian
Other

4. Medication (Are you regularly taking medication for the following?)*

Allergies

Yes No
Blood Pressure

Yes No
Diabetes

Yes No
Cholesterol

Yes No

5. Prevention

(i). Have you had the recommended health preventive screening exams? *

Yes
No

(ii). Annual physical exam within the last 1-2 years *

Yes
No

(iii). Annual Flu Immunization *

Yes
No

(iv). Dental exam within the last year *

Yes
No

(v). Blood Pressure screening within the last year (Eligible Age ≥ 18) *

(Last picked from your Profile as on 01/01/1970)

Yes
No
Does Not Apply (as you are below 18 years of age)

(vi). Cholesterol screening within the last 2-5 years (Male age ≥ 35 or Female ≥ 45) *

Yes
No
Does Not Apply

(vii). Colon Cancer screening the last 5 years (Age ≥ 50) *

(Last picked from your Profile as on 01/01/1970)

Yes
No
Does Not Apply (as you are below 50 years of age)

(viii). Mammography screening within the last 2 years? (Female age ≥ 40) *

Yes
No
Does Not Apply (as you are below 40 years)

(ix). Pap test screening the last 3 years? (Female age ≥ 18 and ≤ 65) *

Yes
No
Does Not Apply (as you are not between the age of 18 to 65 years)

(x). Have you ever received a Tetanus immunization? *

Yes
No
Don't Know